Mastering your fellowship: Part 2, 2024

The 'Mastering your Fellowship' series provides examples of the question format encountered in the written and clinical examinations, Part A of the Fellowship of the College of Family Physicians of South Africa (FCFP [SA]) examination. The series is aimed at helping family medicine registrars prepare for this examination.

Umbilical vein catheterisation for the family physician working in primary health care

This is part of a series of articles on vascular access in emergencies. The other two articles were on intra osseous lines and central venous lines. These are critical lifesaving emergency skills for the primary care professional. In this article, we will provide an overview of umbilical vein catheterisation highlighting its importance, the indications, contraindications, techniques, complications and nursing considerations. By familiarising healthcare providers with this procedure, we hope to enhance their knowledge and skills, ultimately leading to improved outcomes in the neonatal population.

Central venous pressure line insertion for the primary health care physician

Central venous access is an important procedure to understand and perform not only in the emergency unit but also for prolonged reliable venous access. All clinicians must be familiar and confident with this procedure. This paper will focus on applied anatomy in respect of common anatomical sites for venous access, the indications, the contraindications, the technique and complications that may arise following the procedure. This article is part of a series on vascular access. We have previously written on the intra osseous procedure and an article on umbilical vein catheterisation will follow.

Intraosseous line insertion for the primary health care physician

Early rapid access to the vascular system is essential in emergencies and is lifesaving. In this article, we will provide information on the common sites used, the equipment that is required, the indications and contraindications for intraosseous line insertion, how to correctly and safely do the procedure, medication that can be administered, post insertion line management and possible complications. This is a lifesaving procedure and primary healthcare physicians should acquire this skill.

Acute myocardial infarction at a district hospital in KwaZulu-Natal – Management and outcomes

Background

Acute myocardial infarction (AMI) following ischaemic heart disease (IHD) is associated with increased morbidity and mortality. The condition remains a management challenge in resource-constrained environments. This study analysed the management and outcomes of patients presenting with AMI at a district hospital in KwaZulu-Natal.

Methods

A descriptive study that assessed hospital records of all patients diagnosed with AMI over a 2-year period (01 August 2016 to 31 July 2018). Data extracted recorded patient demographics, risk factors, timing of care, therapeutic interventions, follow up with cardiology and mortality of patients.

Results

Of the 140 patients who were admitted with AMI, 96 hospital records were analysed. The mean (standard deviation [s.d.]) age of patients was 55.8 (±12.7) years. Smoking (73.5%) and hypertension (63.3%) were the most prevalent risk factors for patients with ST elevation myocardial infarction (STEMI) in contrast to dyslipidaemia (70.2%) and hypertension (68.1%) in patients with non-ST elevation myocardial infarction (NSTEMI). Almost 49.5% of patients arrived at hospital more than 6 h after symptom onset. Three (12.5%) patients received thrombolytic therapy within the recommended 30-min time frame. The mean triage-to-needle time was 183 min – range (3; 550). Median time to cardiology appointment was 93 days. The in-hospital mortality of 12 deaths considering 140 admissions was 8.6%.

Conclusion

In a resource-constrained environment with multiple systemic challenges, in-hospital mortality is comparable to that in private sector conditions in South Africa. This entrenches the role of the family physician. There is need for more coordinated systems of care for AMI between district hospitals and tertiary referral centres.

Palpitations: Evaluation and management by primary care practitioners

Palpitations are a common, non-specific presenting complaint in primary healthcare and emergency departments. Palpitations are mostly a symptom of benign underlying disease but a sign of life-threatening conditions. Importantly, palpitations are a symptom and not a diagnosis, and cardiac causes are the most concerning aetiology. Clinicians should seek to identify the underlying cause. History and physical examination are important in the assessment of patients with palpitations, and the use of a 12-lead electrographic (ECG) monitor on presentation is the gold standard of diagnosis. If the aetiology cannot be determined, an ambulatory Holter 24–48-h monitor can be used. Treatment and follow-up of patients presenting with palpitations as the main complaint will depend on the aetiology and investigation findings. Patients with palpitations accompanied by dizziness, excessive fatigue, or chest pains should receive adequate acute care aiming to stabilise their condition before referring to a higher level of care.

Demographic profile of patients and risk factors associated with suicidal behaviour in a South African district hospital

Background

Suicidal behaviour comprises self-destructive thoughts coupled with attempts at suicide, which negatively impacts the patient, family, friends, and their community. There is a paucity of data on factors influencing suicidal thoughts and behaviour in South Africa. The aim of this study was to evaluate demographic profile and risk factors associated with suicidal behaviour.

Methods

In this retrospective descriptive and observational study, 282 medical records of patients with suicidal behaviour were studied. The risk factors and age at occurrence were tabulated. Descriptive analyses were undertaken to understand how they were distributed across key socio-demographic groups.

Results

Suicidal behaviour was particularly prominent amongst the female population. The suicidal ideation, plan and non-fatal suicide were reported by 48.6%, 29.1% and 36.5%, of patients respectively. The prevalence for suicidal ideation was significantly higher in females (54.5% vs. 31.5%; p < 0.0007) but not for suicidal plan (28.7% vs. 30.1%; p < 0.81) and suicidal attempt (37.3% vs. 34.2%; p = 0.63) as compared with males. Suicidal behaviour was positively associated with depression (r = 0.56, p < 0.001) and negatively associated with age (r = −0.16, p = 0.01). Multivariate logistic regression analysis revealed that suicidal behaviour was influenced by female gender, poor social support, depression and a family history of non-fatal suicide.

Conclusion

This research has confirmed an association between female sex and factors associated with a higher risk of suicidal behaviour.

Profile and obstetric outcome of teenage pregnancies compared with pregnant adults at a district hospital in KwaZulu-Natal

Background

Teenage pregnancy remains a major public health concern and a challenge for developing countries. Young maternal age can lead to serious physical, social and psychological consequences as teenage mothers are less likely to gain full educational potential and are at higher risk of poverty and complications of pregnancy. The objective of the study was to describe the profile and obstetric outcome of teenage pregnancy compared with that of pregnant adults at a district hospital in KwaZulu-Natal.

Methods

A retrospective descriptive study utilising data obtained from randomly selected hospital records of 216 teenage mothers compared the socio-demographic profile, foetal and maternal outcomes to that of pregnant adults.

Results

The mean age of the teenage group was 17.6 and 26.0 years for the adults (control group). Both groups had a remarkable booking status (97.2% vs. 100%) and antenatal attendance (62.5% vs. 66.2% with ≥ 5 visits). No significant difference in anaemia, caesarean delivery and obstetric complications were found in both groups. There was, however, a significant risk of hypertensive disorder of pregnancy (39.8% vs. 26.4%, p = 0.030) and higher risk of episiotomy being carried out during delivery (31.5% vs. 13.0%). On the other hand, the control group had a significant higher risk of HIV infection (12.5% vs. 38.4% p = 0.000).

Conclusion

The study showed that teenage pregnancy has a similar obstetric risk to adult pregnant patients except for hypertension disorder of pregnancy. Although this study demonstrated improved antenatal attendance by pregnant teenagers, the psychosocial impact on young mothers requires further research.

Malnutrition in children under the age of 5 years in a primary health care setting

In this study, we outlined the types of malnutrition amongst children, the causes of malnutrition intervention at the primary health care level and some recommendations to alleviate childhood malnutrition in South Africa.

A Primary Care Approach to Abdominal Pain in Adults

Abdominal pain is a common presenting problem with multiple aetiologies that often pose diagnostic and therapeutic dilemmas for primary care practitioners. The vague symptomatology and difficult correlation to specific organ pathology obscures clinical findings leading to incorrect diagnoses. Although most presentations of abdominal pain are benign, a significant number of patients have life-threatening conditions that require a meticulous approach to management in order to prevent morbidity and mortality. The skill in assessing patients presenting with abdominal pain is fundamental for all primary care doctors. This review will discuss an approach to the assessment and diagnosis of abdominal pain in the primary care setting.

An overview of the viral haemorrhagic fevers for the primary care doctor

The viral haemorrhagic fevers are infectious diseases that often cause life-threatening illnesses. These diseases are common in the tropical areas of the world, and travel history to an endemic area together with recognising signs and symptoms is essential to aid diagnosis. Treatment is often supportive, and infection control measures need to be instituted early at the point of entry. In this article, we will provide an approach to a patient with viral haemorrhagic fevers in a primary healthcare setting.

A primary care approach to the management of Arthritis

Arthritis is a common condition seen frequently by family practitioners, and there are many types of arthritis. Management of arthritis depends largely on the specific type of arthritis that the patient suffers from. In this article, we will provide the primary care doctor with practical information for managing arthritis, focussing on the management of osteoarthritis and rheumatoid arthritis.

Profile of adult patients admitted with drug-induced liver injury at a district hospital in Pietermaritzburg, KwaZulu-Natal

Background: Drug-induced liver injury (DILI) can be prevented if diagnosed and treated timeously. The identification and primary prevention of DILI risk factors presents the rational means of reducing hospital costs and mortality.Methods: A retrospective chart review was conducted of clinical in-patient records of all adult patients admitted to Northdale Hospital (NDH) with a diagnosis of DILI. Patients with pre-existing liver disease were excluded.Results: A total of 95 patient files with DILI were reviewed. The burden of DILI at NDH over the two-year period was 0.19%. The average age was 38 years, with a slightly higher female preponderance (62.1%). A lower serum albumin level (mean 21.35 g/dl) was significantly associated with DILI (p 0.001). Forty-six patients had a history of alcohol consumption, which increased the risk of DILI (OR 2.1). Of the patients reviewed, 62 (65%) were on antiretroviral therapy (ART) whereas 41 (43%) were on tuberculosis treatment (TBT) at presentation. The most common co-morbidities associated with DILI were HIV (75.7%), TB (43.2%), renal disease (34.7%) and malnutrition (31.6%). The most common hepatotoxins, apart from ART and TBT, were paracetamol (46.3%), cotrimoxazole (32.6%), alcohol (48.4%) and traditional medication (27.4%).Conclusion: This study demonstrated associations with the development of DILI and being female gender, younger age group, hypoalbuminaemia and renal failure. The use of alcohol, traditional medication and the overzealous use and prescription of paracetamol to patients who present with DILI is concerning. The case fatality rate of 14.7% demonstrates the importance of identifying these potential risk factors timeously.

An overview of Pneumocystis jirovecii pneumonia for the African generalist practitioner

Introduction

Pneumocystis jirovecii is the causative organism of Pneumocystis pneumonia (PCP) in humans, which is more common among immunocompromised patients. Classically patients present with fever, non-productive cough, and dyspnoea. In the HIV-infected individuals the symptoms may be subtle at first, but gradually progress over several weeks. In the HIV-uninfected patient, however, the duration of symptoms is shorter and more severe, mainly due to the increased inflammatory response of the HIV-uninfected patient.

Methods

This article focuses on the diagnostic methods and then the management and prophylaxis principles of PCP by reviewing the best current practices and guidelines in Africa.

Conclusion

This overview is presented by clinicians who have experience with PCP and is directed mainly at first-line healthcare providers.

Management of the patient with chronic obstructive airway disease (COPD) in a primary health care context

This paper describes the incidence of chronic obstructive airway disease (COPD), the risk factors, staging, investigations and management of COPD. The differential diagnosis for COPD is also presented as COPD can be confused with other clinical conditions. This paper is presented in practical terms for the clinician working in a primary health care context.

Management of upper gastrointestinal bleeding

This paper will describe the common symptoms, signs and causes of upper gastrointestinal bleeding. We will then provide advice on the management of upper gastrointestinal bleeding at primary care level.

Compliance with local diabetic guidelines at a district hospital in KwaZulu-Natal, South Africa

Background: Diabetes mellitus (DM) represents a major health-related problem in South Africa and throughout the world. The management goals of diabetes are first to maintain normal blood glucose levels and second to prevent the development of complications. Local guidelines developed by the Society for Endocrine Metabolism and Diabetes South Africa (SEMDSA) have shown that tight glycaemic control and appropriate monitoring can prevent or delay the development of diabetic complications. The demographic profile of patients with type 2 DM and the compliance of doctors to the guidelines were determined.Methods: Five hundred records of patients with type 2 DM were selected from the medical outpatients’ department (MOPD) by systematic sampling. Demographic information on age, sex and ethnicity was obtained. The performance and timing of recommended investigations were recorded and compared with the 2012 SEMDSA guidelines.Results: The mean age of patients was 61 years. Black and Indian patients formed the majority, comprising 44.4% and 43.0% respectively. Glycated haemoglobin was measured in 29.2% of patients once and 13.2% of patients twice in the past year. Lipid studies were done on 40.4% of patients. A serum creatinine (sCr), estimated glomerular filtration rate (eGFR) and serum potassium were done on 38.2% of patients. Eye examinations were done on 13.60% patients and examination of the foot was done on 7.8% of patients. Some 15% had a urine dipstick test done at least once in the past year and 10.4% had a urine albumin/creatinine ratio (ACR) requested. Only 21 patients (4.2%) were compliant with the SEMDSA guidelines. Measurements of blood pressure and blood glucose were 100% compliant. Anthropometric measurements (height, weight and body mass index), dietitian referral and foot examinations were the least compliant, being performed 4.2%, 5.0% and 7.8% of the time respectively.Conclusion: Black and Indian patients formed the majority of the study population. The screening for chronic complications of type 2 DM was poor in the majority of patients. Evaluation of selected records demonstrated compliance with the SEMDSA guidelines in only 4.2% of patients. There is an urgent need to review barriers to the implementation of guidelines in South Africa.

Susceptibility to hepatitis B infection, hepatitis B/HIV co-infections and hepatitis B immunity in HIV-positive patients starting HAART in Durban, South Africa

Background: HIV/HBV co-infection remains a global threat to HIV management despite the available effective hepatitis B vaccine and hepatitis B covering antiretroviral therapy. Many studies done in South Africa and internationally showed high prevalence of HIV/hepatitis B co-infection, which mandated routine screening for both infections before initiating HAART. Fewer studies have highlighted the prevalence of hepatitis B susceptibility in the general population starting HAART and most of them were limited to children and high-risk groups. The aim of this study was to demonstrate the extent of hepatitis B susceptibility, hepatitis B/HIV co-infections and hepatitis B immunity in general HIV-infected patients.Method: This was a retrospective review of 1 066 randomly sampled files of patients initiated on HAART between January 2012 and December 2014 at two Durban hospitals. Data collection included demographic characteristic, CD4 counts and hepatitis B serology. Data were analysed for the prevalence of hepatitis B susceptibility, HIV/HBV co-infection and hepatitis B immunity, while correlations between age, CD4 count and these three groups were demonstrated. Statistical analysis was performed using SAS version 9.3.Results: Total prevalence of HBV susceptibility was 69.7%, HBV immunity was 26.9% and true chronic HIV/HBV co-infection was 3.4%, while HBVsAg positivity accounted for 8.4% of the participants. Adults were more susceptible to HBV than children, with a median age of 36 years. Stratified for age, children were more immune (90%) to HBV than adults.Conclusion: This study demonstrated a significantly high number of HIV-infected persons who were susceptible to hepatitis B infection in Durban, South Africa, where both HIV and HBV are endemic, co-infection is high, and safe and effective HBV vaccine is available. Hepatitis B vaccination of the hepatitis B susceptible patients initiating HAART in South Africa is recommended to prevent further HIV/HBV co-infection.

Plasma noradrenaline and adrenaline levels in eclampsia. A preliminary study

Plasma noradrenaline and adrenaline levels were measured in 18 women with eclampsia and 20 normotensive pregnant women matched for age and parity. While plasma noradrenaline concentrations were not statistically different in the two groups, plasma adrenaline values were higher in patients with eclampsia. The increases in adrenaline levels, although significantly elevated, were thought to be more related to stresses, such as muscular activity associated with convulsions. This study suggests that the aetiology of hypertension in pregnancy is not related to sympathetic overactivity.